Simkins Staff Daily Entry Form
1. Staff Member Completing Form *
2. Today's date *
MM
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DD
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YYYY
3. Have you had contact (within 6 feet for at least 15 minutes) with someone who has been diagnosed with Covid 19 in the last 14 days? *
4. Has the health department or your healthcare provider been in contact with you and advised you to quarantine? *
5. Have you had any of these symptoms in the last 14 days? Please check all that apply. *
Required
6. Since you were last at school have you been diagnosed with Covid 19? *
If your answers for questions 3, 4 or 6 were "yes" OR if you have any of the symptoms that were outlined in question 5, please plan to stay home and contact Zimmerman or Vaka to discuss.
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